Roberto Catalán

Surgically induced weight loss by gastric bypass improves non alcoholic fatty liver disease in morbid obese patients

AIM To evaluate the effects of surgical weight loss (Roux-en-Y gastric bypass with a modified Fobi-Capella technique) on non alcoholic fatty liver disease in obese patients. METHODS A group of 26 morbidly obese patients aged 45 ± 2 years and with a body mass index > 40 kg/m(2) who underwent open surgical weight loss operations had paired liver biopsies, the first at surgery and the second after 16 ± 3 mo of weight loss. Biopsies were evaluated and compared in a blinded fashion. The presence of metabolic syndrome, anthropometric and biochemical variables were also assessed at baseline and at the time of the second biopsy. RESULTS Percentage of excess weight loss was 72.1% ± 6.6%. There was a reduction in prevalence of metabolic syndrome from 57.7% (15 patients) to 7.7% (2 patients) (P < 0.001). Any significance difference was observed in aspartate aminotransferase or alanine aminotransferase between pre and postsurgery. There were improvements in steatosis (P < 0.001), lobular (P < 0.001) and portal (P < 0.05) inflammation and fibrosis (P < 0.001) at the second biopsy. There were 25 (96.1%) patients with non alcoholic steatohepatitis (NASH) in their index biopsy and only four (15.3%) of the repeat biopsies fulfilled the criteria for NASH. The persistence of fibrosis (F > 1) was present in five patients at second biopsy. Steatosis and fibrosis at surgery were predictors of significant fibrosis postsurgery. CONCLUSION Restrictive mildly malabsorptive surgery provides significant weight loss, resolution of metabolic syndrome and associated abnormal liver histological features in most obese patients.

Twelve-Month Estrogen Levels in Premenopausal Women With Hormone Receptor–Positive Breast Cancer Receiving Adjuvant Triptorelin Plus Exemestane or Tamoxifen in the Suppression of Ovarian Function Trial (SOFT): The SOFT-EST Substudy

PURPOSE To describe estradiol (E2), estrone (E1), and estrone sulfate (E1S) levels during the first year of monthly triptorelin plus exemestane or tamoxifen and to assess possible suboptimal suppression while receiving exemestane plus triptorelin. PATIENTS AND METHODS Premenopausal patients with early breast cancer on the Suppression of Ovarian Function Trial who selected triptorelin as the ovarian suppression method and were randomly assigned to exemestane plus triptorelin or tamoxifen plus triptorelin were enrolled until the target population of 120 patients was reached. Blood sampling time points were 0, 3, 6, 12, 18, 24, 36, and 48 months. Serum estrogens were measured with a highly sensitive and specific assay. This preplanned 12-month analysis evaluated E2, E1, E1S, follicle-stimulating hormone, and luteinizing hormone levels in all patients and the proportion of patients with E2 levels greater than 2.72 pg/mL at any time point during treatment with exemestane plus triptorelin. RESULTS One hundred sixteen patients (exemestane, n = 86; tamoxifen, n = 30; median age, 44 years; median E2, 51 pg/mL; 55% prior chemotherapy) started triptorelin and had one or more samples drawn. With exemestane plus triptorelin, median reductions from baseline E2, E1, and E1S levels were consistently ≥ 95%, resulting in significantly lower levels than with tamoxifen plus triptorelin at all time points. Among patients on exemestane plus triptorelin, 25%, 24%, and 17% had an E2 level greater than 2.72 pg/mL at 3, 6, and 12 months, respectively. Baseline factors related to on-treatment E2 level greater than 2.72 pg/mL were no prior chemotherapy (P = .06), higher body mass index (P = .05), and lower follicle-stimulating hormone and luteinizing hormone (each P < .01). CONCLUSION During the first year, most patients on exemestane plus triptorelin had E2 levels below the defined threshold of 2.72 pg/mL, consistent with levels reported in postmenopausal patients on aromatase inhibitors, but at each time point, at least 17% of patients had levels greater than the threshold.

Alterations in the Common Pathway of Coagulation During Weight Loss Induced by Gastric Bypass in Severely Obese Patients

The objective of this study was to establish the relationship between the plasminogen activator inhibitor‐1 (PAI‐1), antithrombin‐III (ATIII), fibrinogen, and white blood cell (WBC) levels in severely obese patients. We analyzed various plasma parameters implicated in the intrinsic and extrinsic coagulation pathway from 34 severely obese patients before and 1, 6, and 12 months after gastric bypass. In obese people, ATIII, fibrinogen, and WBC levels were in the upper limit of the normal range, and all were higher and significantly different from nonobese people. After bariatric surgery, the ATIII level continued to be high during the first month and increased until 12 months, while fibrinogen decreased only at that time. PAI‐1 plasma protein and PAI‐1 mRNA levels in liver and adipose tissue show similar profiles and had a strong positive correlation (r = 0.576, P = 0.0003 in liver; r = 0.433, P = 0.0004 in adipose tissue). They were higher in obese patients compared with nonobese control, but tended to recover normal values 1 month after surgery. Thus, the liver and adipose tissue could be an important source of PAI‐1 protein in plasma. Gastric bypass surgery leads to a normalization of the hematological profile and a decrease in PAI‐1 levels, which entails a decrease of risk for thromboembolism in severely obese.

Soluble CD40 ligand in morbidly obese patients: effect of body mass index on recovery to normal levels after gastric bypass surgery.

IMPORTANCE In recent years, the CD40/CD40L system has been implicated in the pathophysiology of severe chronic inflammatory diseases. Recently, obesity has been described as a low chronic inflammatory disease, so this system could also be involved in the inflammatory process. OBJECTIVE To study soluble CD40 ligand (sCD40L) and other factors implicated in coagulation (plasminogen activator inhibitor 1, antithrombin III, and fibrinogen) and inflammation (C-reactive protein) in patients with morbid obesity and different body mass indexes (BMIs) (calculated as weight in kilograms divided by height in meters squared), before and after weight loss induced by bariatric surgery. DESIGN Plasma samples were obtained before and after a bariatric surgery intervention. Several inflammatory markers were then studied (sCD40L, plasminogen activator inhibitor 1, antithrombin III, and C-reactive protein). The values obtained were compared with a control group of nonobese persons. PARTICIPANTS Thirty-four morbidly obese patients undergoing gastric bypass surgery and 22 normal-weight controls matched for age and sex. INTERVENTIONS A Roux-en-Y gastric bypass was performed in morbidly obese patients. MAIN OUTCOME MEASURES Levels of sCD40L, plasminogen activator inhibitor 1, antithrombin III, fibrinogen, and C-reactive protein 12 months after bariatric surgery. RESULTS Obese men showed a tendency for decreased plasma sCD40L levels 1 year after surgery (mean [SEM], 246.5 [70.4] pg/mL before vs 82.2 [23.2] pg/mL after surgery; P < .05), whereas there were not any significant changes in obese women (285.9 [67.5] pg/mL before vs 287.0 [56.9] pg/mL after surgery). Levels of the other markers studied decreased significantly with weight loss in both sexes. However, all other studied markers tend to have higher concentrations in patients with higher BMIs, except for sCD40L, which tended to have lower concentrations in patients with BMIs higher than 55. The decreases with weight loss were lower with higher BMIs for all measurements, except for antithrombin III. CONCLUSIONS AND RELEVANCE Increased BMI, but not sex, influences recovery to normal levels for the markers studied, possibly indicating a worse prognosis.

Utilidad de la determinación intraoperatoria de parathormona en el tratamiento quirúrgico del hiperparatiroidismo primario por adenoma de paratiroides

Fundamento y objetivo La exploracion quirurgica de las 4 paratiroides es un procedimiento demasiadoagresivo para la mayoria de los casos de hiperparatiroidismo primario (HPTP) cuya causa es un adenoma preoperatoriamente localizado. Recientemente la determinacion intraoperatoria de paratormona (PTH) ha demostrado ser una herramienta util en el tratamiento de estos pacientes y permitiria el uso de tecnicas quirurgicas minimamente invasivas, con una menor morbilidad. El objetivo de nuestro trabajo es la valoracion de la utilidad de la determinacion intraoperatoria de la PTH en el abordaje quirurgico del HPTP. Pacientes y metodo Se incluyo a 27 pacientes consecutivos, diagnosticados de HPTP causado por un adenoma de paratiroides. El estudio de localizacion consto de ecografia cervical y gammagrafia con Tc-MIBI. Durante la intervencion, se determino la PTH en el momento de la induccion anestesica y 5 y 10 min despues de la exeresis del adenoma. Un descenso de la PTH mayor del 50% a los 10 min se considero criterio de curacion. La PTH se determino por un metodo quimioluminimetrico (Advantage, Nichols). El tiempo necesario para la obtencion del resultado fue de 20 min. Resultados En los 27 casos no existio hipercalcemia 24 h despues de la intervencion, por loque se consideraron curados. La PTH disminuyo mas de un 50% en todos ellos. En un caso, la PTH se mantuvo elevada despues de extirpar una lesion que se habia localizado preoperatoriamente. El dictamen patologico fue que se trataba de un tejido paratiroideo normal. La continuacion de la exploracion quirurgica permitio encontrar un adenoma en el lado contralateral. La PTH posterior fue menor del 50%. Por tanto, de las 28 determinaciones, la PTH fue predictiva del resultado quirurgico en la totalidad de los casos. Conclusiones La determinacion intraoperatoria de PTH es util en el abordaje quirurgico del HPTP y permite el uso de tecnicas quirurgicas minimamente invasivas.

Study of different factors affecting arginine-vasopressinradioimmunoassay

Since Robertson et al’s description of a radioimmunoassay (RIA) method [l] for the deter~nation of ar~nine-vasopressin (AVP) in human plasma, there have been several reports on the same subject. Some of the methods are not sensitive enough [2-81 for the detection of low levels of AVP in plasma, while others, although sensitive enough to detect these levels [9-161, use extraction methods which are too laborious. In addition, there is no general agreement on the stability of the samples ]7,9,10,13]. In this paper, we describe a sensitive method for plasma AVP measurement using a commercial antiserum and a simple method for extraction [7]. To obtain a labelled hormone with adequate specific activity and purity, most of the experimental work was dedicated to a detailed study of the purification procedure. The consequences of using metabisulphite in the iodination are discussed. We also report the results of a study on stability of AVP values in freeze-dried samples.